Seeing but not believing: Insights into the intractability of failure to fail.
Journal
Medical education
ISSN: 1365-2923
Titre abrégé: Med Educ
Pays: England
ID NLM: 7605655
Informations de publication
Date de publication:
12 2020
12 2020
Historique:
received:
28
01
2020
revised:
04
05
2020
accepted:
10
06
2020
pubmed:
21
6
2020
medline:
24
6
2021
entrez:
21
6
2020
Statut:
ppublish
Résumé
Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee. Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place. Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility. Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1148-1158Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.
Références
Dudek NL, Marks MB, Regehr G. Failure to fail: the perspectives of clinical supervisors. Acad Med. 2005;80(Suppl 10):S84-S87.
Barrett A, Galvin R, Steinert Y, et al. A BEME (best evidence in medical education) review of the use of workplace-based assessment in identifying and remediating underperformance among postgraduate medical trainees: BEME Guide No. 43. Med Teach. 2016;38(12):1188-1198.
Yepes-Rios M, Dudek N, Duboyce R, Curtis J, Allard RJ, Varpio L. The failure to fail underperforming trainees in health professions education: a BEME systematic review: BEME Guide No. 42. Med Teach. 2016;38(11):1092-1099.
Daelmans HEM, Mak-van der Vossen MC, Croiset G, Kusurkar RA. What difficulties do faculty members face when conducting workplace-based assessments in undergraduate clerkships? Int J Med Educ. 2016;7:19-24.
Mak-van der Vossen M, Peerdeman S, van Mook W, Croiset G, Kusurkar R. Assessing professional behaviour: overcoming teachers’ reluctance to fail students. BMC Res Notes. 2014;7(1):368.
Christensen MK, O’Neill L, Hansen DH, Norberg K, Mortensen LS, Charles P. Residents in difficulty: a mixed methods study on the prevalence, characteristics, and sociocultural challenges from the perspective of residency program directors. BMC Med Educ. 2016;16(1):69.
Dennis AA, Foy MJ, Monrouxe LV, Rees CE. Exploring trainer and trainee emotional talk in narratives about workplace-based feedback processes. Adv Health Sci Educ Theory Pract. 2018;23(1):75-93.
Bandiera G, Lendrum D. Daily encounter cards facilitate competency-based feedback while leniency bias persists. Can J Emerg Med. 2008;10(1):44-50.
McQueen SA, Petrisor B, Bhandari M, Fahim C, McKinnon V, Sonnadara RR. Examining the barriers to meaningful assessment and feedback in medical training. Am J Surg. 2016;211(2):464-475.
Guerrasio J, Furfari KA, Rosenthal LD, Nogar CL, Wray KW, Aagaard EM. Failure to fail: the institutional perspective. Med Teach. 2014;36(9):799-803.
Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012. Acad Med. 2014;89(2):352-358.
Watling CJ, Kenyon CF, Schulz V, Goldszmidt MA, Zibrowski E, Lingard L. An exploration of faculty perspectives on the in-training evaluation of residents. Acad Med. 2010;85(7):1157-1162.
Kogan JR, Conforti LN, Bernabeo EC, Durning SJ, Hauer KE, Holmboe ES. Faculty staff perceptions of feedback to residents after direct observation of clinical skills. Med Educ. 2012;46(2):201-215.
Alexander EK, Osman NY, Walling JL, Mitchell VG. Variation and imprecision of clerkship grading in us medical schools. Acad Med. 2012;87(8):1070-1076.
Adams KE, Emmons S, Romm J. How resident unprofessional behavior is identified and managed: a program director survey. Am J Obstet Gynecol. 2008;198(6):692. e1-e5.
Nixon LJ, Gladding SP, Duffy BL. Describing failure in a clinical clerkship: implications for identification, assessment and remediation for struggling learners. J Gen Intern Med. 2016;31(10):1172-1179.
McGill D, van der Vleuten C, Clarke M. Supervisor assessment of clinical and professional competence of medical trainees: a reliability study using workplace data and a focused analytical literature review. Adv Health Sci Educ. 2011;16(3):405-425.
Pangaro L, ten Cate O. Frameworks for learner assessment in medicine: AMEE Guide No. 78. Med Teach. 2013;35(6):e1197-e1210.
General Medical Council. Good medical practice. [GMC website]. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice. Accessed March 8, 2020.
Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29(7):642-647.
Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29(7):648-654.
Hauer KE, Ciccone A, Henzel TR, et al. Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature. Acad Med. 2009;84(12):1822-1832.
Caulford PG, Lamb SB, Kaigas TB, Hanna E, Norman GR, Davis DA. Physician incompetence: specific problems and predictors. Acad Med. 1994;69(Suppl 10):S16-S18.
Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000;284(9):1099-1104.
Dupras DM, Edson RS, Halvorsen AJ, Hopkins RH, McDonald FS. ‘Problem residents’: prevalence, problems and remediation in the era of core competencies. Am J Med. 2012;125(4):421-425.
Crossley J, Johnson G, Booth J, Wade W. Good questions, good answers: construct alignment improves the performance of workplace-based assessment scales. Med Educ. 2011;45(6):560-569.
Holmboe ES, Edgar L, Hamstra S. The Milestones Guidebook. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016.
Hodges B. Medical education and the maintenance of incompetence. Med Teach. 2006;28(8):690-696.
Cleland J, Leggett H, Sandars J, Costa MJ, Patel R, Moffat M. The remediation challenge: theoretical and methodological insights from a systematic review. Med Educ. 2013;47(3):242-251.
Yao DC, Wright SM. The challenge of problem residents. J Gen Intern Med. 2001;16(7):486-492.
Rees CE, Knight LV, Cleland JA. Medical educators’ metaphoric talk about their assessment relationships with students: ‘You don’t want to sort of be the one who sticks the knife in them.’ Assess Eval High Educ. 2009;34(4):455-467.
Charmaz K. Constructing Grounded Theory. London, UK: SAGE Publications Ltd.; 2014:1-416.
Mak-van der Vossen M, van Mook W, van der Burgt S, et al. Descriptors for unprofessional behaviours of medical students: a systematic review and categorisation. BMC Med Educ. 2017;17(1):164.
Bourgeois-Law G, Varpio L, Regehr G, Teunissen PW. Education or regulation? Exploring our underlying conceptualisations of remediation for practising physicians. Med Educ. 2019;53(3):276-284.
Dweck CS, Yeager DS. Mindsets: a view from two eras. Perspect Psychol Sci. 2019;14(3):481-496.
Dreon R. Framing cognition: Dewey’s potential contributions to some enactivist issues. Synthese. 2019;1-22. https://doi.org/10.1007/s11229-019-02212-x
Elkjaer B. Pragmatism: a learning theory for the future. In: Illeris K, ed. Contemporary Theories of Learning. Philadelphia, PA: Routledge; 2009:82-97.
Taleb NN. Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets, 2nd edn. New York, NY: Thomson/Texere; 2004.
Proulx T. The feeling of the absurd: towards an integrative theory of sense-making. Psychol Inq. 2009;20(4):230-234.
Proulx T, Inzlicht M, Harmon-Jones E. Understanding all inconsistency compensation as a palliative response to violated expectations. Trends Cogn Sci. 2012;16(5):285-291.
Scarff CE, Bearman M, Chiavaroli N, Trumble S. Keeping mum in clinical supervision: private thoughts and public judgements. Med Educ. 2019;53(2):133-142.
Cleland JA, Knight LV, Rees CE, Tracey S, Bond CM. Is it me or is it them? Factors that influence the passing of underperforming students. Med Educ. 2008;42(8):800-809.
Humphrey-Murto S, LeBlanc A, Touchie C, et al. The influence of prior performance information on ratings of current performance and implications for learner handover: a scoping review. Acad Med. 2019;94(7):1050-1057.
Jervis A, Tilki M. Why are nurse mentors failing to student nurses who do not meet clinical performance standards? Brit J Nurs. 2011;20(9):582-587.
Fazio SB, Papp KK, Torre DM, DeFer TM. Grade inflation in the internal medicine clerkship: a national survey. Teach Learn Med. 2013;25(1):71-76.
Harmon-Jones E, Harmon-Jones C. Cognitive dissonance theory after 50 years of development. Z Sozialpsychol. 2007;38(1):7-16.
Festinger L, Riecken HW, Schachter S. When Prophecy Fails: A Social and Psychological Study of a Modern Group that Predicted the Destruction of the World. New York, NY: Harper Torchbooks; 1956.
Brannon SM, Gawronski B. Cognitive consistency in social cognition. In: Hogg M, ed. The Oxford Encyclopedia of Social Psychology. New York, NY: Oxford University Press; 2018.
Harmon-Jones E, Harmon-Jones C, Levy N. An action-based model of cognitive-dissonance processes. Curr Dir Psychol Sci. 2015;24(3):184-189.
Mak-van der Vossen M. ‘Failure to fail’: the teacher's dilemma revisited. Med Educ. 2019;53(2):108-110.
Lankshear A. Failure to fail: the teacher's dilemma. Nurs Stand. 1990;4(20):35-37.
Rekman J, Gofton W, Dudek N, Gofton T, Hamstra SJ. Entrustability scales: outlining their usefulness for competency-based clinical assessment. Acad Med. 2016;91(2):186-190.
Ginsburg S, McIlroy J, Oulanova O, Eva KW, Regehr G. Toward authentic clinical evaluation: pitfalls in the pursuit of competency. Acad Med. 2010;85(5):780-786.
Ginsburg S, Gold W, Cavalcanti RB, Kurabi B, McDonald-Blumer H. Competencies, ‘plus’: the nature of written comments on internal medicine residents' evaluation forms. Acad Med. 2011;86(Suppl 10):S30-S34.
White JS, Sharma N. ‘Who writes what?’ using written comments in team-based assessment to better understand medical student performance: a mixed-methods study. BMC Med Educ. 2012;12(1):123.
Ginsburg S, Regehr G, Lingard L, Eva KW. Reading between the lines: faculty interpretations of narrative evaluation comments. Med Educ. 2015;49(3):296-306.
Bacchus M, Ward DR, de Grood J, Lemaire JB. How evidence from observing attending physicians links to a competency-based framework. Med Educ. 2017;51(6):633-644.